Is it our job to educate RNs for Canada or for the United States?

The following is a guest blog by Dr. Jennifer Medves, Vice-Dean (Health Sciences) and Director of the School of Nursing at Queen’s University.

In December 2011, the College of Nurses of Ontario (CNO), and the regulators across the country, announced that as of January 1, 2015, graduates of nursing programs would no longer be required to pass the Canadian Registered Nurses Exam.[i]

The same press release stated that the National Council of State Boards of Nursing had been selected “… to partner in the development of a state-of-the-art, computer-adaptive RN entry exam.” The statement went on to clarify that in order “… to ensure the exam meets Canadian requirements, the ten regulators will participate in oversight of the exam development and administration.” The wording of the press release, including words such as “partner” and “exam development and administration,” suggested to educators that this would be a new, Canadian-based nursing exam that would be housed on the National Council of State Boards of Nursing computer system.

Instead, we later discovered that our nursing students would be required to pass the NCLEX-RN – an American nursing exam. What followed was an overwhelming sense that we had lost a huge battle without even knowing one was occurring. While there was much rhetoric about the exam, we were subsequently assured that nursing practice is the same on both sides of the border, that all questions on the exam with American-only content would be excluded for Canadian students, and that the decision was final and irrevocable. That said, our concerns remained and we began to petition everyone we could to try and reverse the decision while simultaneously helping to prepare our students for the exam. Nursing faculty from across the country went to every available conference, seminar, and webinar to try and find out as much as possible about the NCLEX-RN.

At the same time, we were inundated with American advertising that assured us that we needed help from all types of for-profit organizations to ensure we met the requirement in our programs to achieve the pass rate of 88% for all our students. At Queen’s we were naturally horrified that an 88% pass rate was considered to be good! With the CRNE, our expectation has always been a 100% pass rate, and we become very concerned if we have more than one failure.

Overwhelmed by the ever-increasing amount of advertising that we were receiving, we partnered with the 13 other university nursing programs in Ontario and conducted a thorough assessment of all of the ‘help’ on offer. Through an RFP process, we selected two organizations to provide teaching material at a reduced rate to all universities. One of the criteria was that written material would be available in French, and both organizations selected assured us that material would be bilingual. To date, this requirement has been partially met and is very sparse.

We all worked diligently to include NCLEX-RN type questions into our assessment of nursing knowledge across the curriculum. We reassured our students that former Queen’s nursing graduates who were interested in working in the US had taken the test in the past and had fared well. We tried to avoid unduly alarming the students, but encouraged them to purchase new study guides and study really hard.

Unfortunately, when the exam was rolled out, our worst fears came true. The media began to report on some of the student experiences in taking the exam, some of who described it as “terrible,” “biased,” and “a crapshoot.”[ii] While many were embarrassed of the high failure rate and wondered about the damage to our reputation by going public, the College of Nurses of Ontario publishes the rates on their website for the whole world to read and the damage to the reputation of Canadian educated nurses is already done.

The Canadian Association of Schools of Nursing (CASN) carefully mapped the entry-to-practice competencies required of new nursing graduates in Canada against the NCLEX-RN specified test areas, and the results were frustrating. “One third of the competencies expected of a Canadian nurse are not addressed at all by the NCLEX-RN and over a quarter are only partially tested. This represents more than half of the competencies” explained Dr. Cynthia Baker, Executive Director of CASN and Professor Emerita of the Queen’s School of Nursing. “Examples of what is missing include nursing activities reflecting national guidelines related to patient safety, interprofessional collaboration, client-centred care, and cultural safety, each of which is an essential element of patient safety in the Canadian context. By the same token, many activities listed in the NCLEX-RN test plan aren’t among the required entry-to-practice competencies.”[iii]

The outcome of the exam roll-out has not only concerned the nursing community. Reza Moridi, the Minister of Training, Colleges and Universities agrees that Canadian nurses should be tested using a Canadian exam. “Our regulatory colleges, including the College of Nurses, should design a Canadian exam rather than borrowing something from other countries,” he told the Toronto Sun. He also dismissed the high Canadian failure rate as a signal of our teaching standards. “Our colleges and universities are training first-class nurses. Our nursing graduates — their education, their work ethic — are among the best in the world.”[iv]

Moridi went on to say he has great confidence in Ontario nursing schools, which educate 4,500 students each year. “They have to design their own Canadian or Ontario exam which suits our requirements and follows the metric system instead of the imperial system, which is very different and could be very confusing,” Moridi said. “Also, the French translation should be perfect.” [v]

Health Minister Eric Hoskins says since this is the first year the test has been used, it’s important to get it right. “I think we all agree that the exam that a health-care practitioner should take in this province should reflect the curriculum that they’re taught and that it should be a useful tool to measure their preparedness for entering the workforce,” he told the Toronto Sun. [vi]

So where does this leave us in the profession of nursing? Disappointed, angered for the students, and feeling absolutely helpless.

Is it truly the long term plan for our Canadian health care professionals to be tested using American exams? Other than serving to improve portability, what does this really accomplish? We spend four years with our students, preparing them for the reality of Canadian health care, teaching patient safety, interprofessional collaboration, client-centred care, and cultural safety. Should we not bother? Are we now in the business of preparing our nurses for the US? I certainly hope not.

Please join me in supporting and advocating for our Canadian nursing graduates in the comments below.

Beryl Cable-Williams

Canadian-educated nurses have long been sought after around the world. Their reputation for highest quality knowledge, skill and judgement attests to the excellent quality of nursing education available in Canadian schools of nursing. The quality of education did not change for the cohort that has been required to write the American-based exam. The only thing that has changed is the nature of the exam as described in the article above. Any suggestion that NCLEX exam results reflect negatively on the quality of the education is patently false.

Donna Brunskill

That the CNA exam needed to change, there was no question. It needed to be computer adaptive, rich R and D, have a link to American mobility formula, valid against 4- year Canadian competencies and enabling of safety assessment and RN mobility. That being said, CNA needed to be a key player, as did CASN. Have we all been too exclusive in our orgs? Now we need to be inclusive and more public/citizen centered than ever before in our approach. We need a strong nursing voice focused on the public interest ( CNA) and it has been being effectively dismantled for over a decade. ” we looked for the enemy and it was us”

Stephen

I thank you for taking the time to blog on the NCLEX, currently a highly contentious topic among the nursing community
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I was invited by Pearson VUE, the company contracted to write the questions for the NCLEX, to attend their Chicago offices to form part of a five person panel of staff nurses for the purpose of reviewing potential NCLEX questions. As part of this strictly volunteer opportunity, I was privy to the test development process and had the chance to talk to question writers (who are masters prepared nurses) and psychometrists. I can attest to the high degree of rigor employed with their test development process.

During this opportunity, I reviewed over 900 potential NCLEX questions. A total of five questions were not suitable for the Canadian context which Pearson VUE promptly discarded when I brought these to their attention.

I am discontented when I hear the term “American exam”. I feel that nursing is quite similar on both sides of the border and Pearson VUE has done due diligence to ensure that the test content is neutral with respect to this.

Furthermore, I can not disagree more with Minister Moridi when he states “They have to design their own Canadian or Ontario exam which suits our requirements and follows the metric system instead of the imperial system”. I can verify that all values expressed in the NCLEX are in metric units and all pharmaceuticals use a name that is recognized in Canada. This demonstrates how misinformed stakeholders are regarding the NCLEX which dangerously propagates to nursing students to create nothing but confusion.

I would encourage all educators to look beyond the current rhetoric and you will find a test that I believe is well suited to measure a nursing student’s preparedness for the workforce.

Jennifer Medves

Thank you Stephen for your comment. I entirely agree with you that the process for developing questions is both rigorous and meets high standard of psychometrics. That is not the issue. The issue as I stated in the first sentence was that we were assured that the exam would meet Canadian requirements. I disagree that all questions are appropriate. You have reviewed potential questions. Our students took existing questions from the test bank and Canadian reviewers have only recently been included. I recognize that there are differences of opinion on this issue and all should be aired. I also wish to thank you for volunteering your time to be on the development teams and I can only hope your presence with exclude inappropriate questions on future exams. At this time we have multiple examples from many students across the country that there were inappropriate questions and the French Translation was not at the required standard.

Gillian Holland

as a graduate who wrote the first Canadian made RN exams and later became an item write I am angered and dismayed at this new move to then American model? Why was it made to promote mobility? I think Canadian educated nurses were examined on a higher standard than the Amaricans.
Gill Holland RN. BNSc.

Jennifer Medves

Thank you Gillian for your response. I had always hoped that an entry to practice exam matched the entry to practice competencies identified in Canada. it may have not been a decision to promote mobility but it will certainly make it easier for graduates to apply for jobs south of the border

Tom Fiala, MD

As a plastic surgeon (and Queen’s grad) who has taken both the American Board of Plastic Surgery and the Royal College Board exams, I can tell you that the long-answer & essay format Canadian written exam was considerably more comprehensive and difficult, compared to the multiple choice test of the US organization. Both were very different experiences. The tests don’t reflect differences of practice in the two countries; they reflect the academic aims of the test-makers and the culture of each licensing organization. Perhaps this is also true with the two different nursing exams – that the test makers have different goals in mind? IMO, Canadian nurses should have a Canadian test, with reciprocity for those who wish to go the US.

Jennifer Medves

Thank you Tom for your comment. I entirely agree that Canadian nurses should have a Canadian test and if they want to work in another country then they need to take the entry to practice exam in that country. I was required to take the Canadian exam when I moved to Canada even though I had a licence in the UK and I accepted this as quite normal. The Queen’s students who want to work south of the border have taken the American exam for years and have long recognized that it does not reflect nursing practice in Canada and that the exam was quite different than the Canadian exam

Courtney H

Canadian Nursing Student’s Association (CNSA) official statement re: NCLEX results. Hopeful that the nursing community can band together to help resolve this issue for our students, as they are the ones who are ultimately suffering.